"Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature" - Principle 1 of the Rio Declaration on Environment and Development, 1992.

This note responds to the request by the co-chairs of the UNCSD Bureau dated 14th March 2011 for contributions and inputs for the preparation of a compilation document which will in turn be used to prepare the zero draft of the UNCSD Rio +20 outcome document. The preamble reflects the fact that WHO's contribution will be part of a UN-wide effort. The second section places the health - and the role of the World Health Organization - within this broader context

Preamble

1. As a member of the United Nations System Chief Executives Board, WHO recognizes the historic opportunity provided by the United Nations Conference on Sustainable Development to reset the world on a sustainable development path.

2. We affirm that sustainable development is a top priority for our organizations, and reaffirm the continuing validity of the principles in the 1992 Rio Declaration on Environment and Development and of Agenda 21, including the principle of common but differentiated responsibilities. We recommit to a renewed system-wide effort, in partnership with the full range of governmental, civil society and private sector stakeholders, to support the realization of these principles.

3. Despite substantial improvement in many key areas of development and environment, the world has not made the progress towards sustainable development aspired to in the outcomes of the United Nations Conference on Environment and Development held in Rio de Janeiro in 1992, and in subsequent related world conferences.

4. Over the past twenty years, the world has witnessed strong economic growth and significant progress towards attaining a number of the Millennium Development Goals (MDGs). It is of grave concern, however, that these positive trends have been accompanied by increasing disparities and inequalities, persistent gender inequality, social inequity, a growing deterioration of the environment, and recurrent economic, financial, energy and food crises.

5. At the United Nations Conference on Sustainable Development (or Rio+20), renewed commitment and urgent action are therefore needed to lay a firm foundation for a longer-term process of redressing imbalances, agreeing on priorities, and reforming institutional arrangements at all levels, to bring about coherence and the integration of policies across the economic, environmental and social pillars, with human beings and their wellbeing at the centre. The Conference must also address the means of implementing outcomes, through the provision of resources, including for technological transformation and capacity building.

6. Charting the way forward to eradicate poverty and promote sustainable development must start with the recognition that the world has changed in fundamental ways. Climate change is significantly altering the physical and human geography of the planet. There are major differences in population growth, age, sex structures, spatial distribution and patterns of movement; resource consumption has increased, and production patterns are more unsustainable. But there has also been wide-ranging technological progress, from renewable energy and energy efficiency, to innovative measures for adapting to climate change impacts, and new and efficient means for social networking, dialogue and participatory engagement, providing opportunities that were not available twenty years ago.

7. Against these changing parameters, Rio+20 must acknowledge that economic, social and environmental objectives are not independent variables, but are mutually supportive, with progress in each area facilitating advancement in the others. Our objectives should be to enhance equity, revitalize the global economy, and protect the planet and its ecosystems that support us so that all people, women, men and children, can live in dignity.

8. The sustainability of future growth and development will rely critically on innovation, improved economic, energy and natural resource efficiency, an open and supportive multilateral trading system, better fiscal policies providing incentives for sustainability, comprehensive wealth accounting and valuation of ecosystem services, equitable access and inclusive political processes and the capacity to create sufficient decent work. Growth must lead to strengthened resilience ? of households, ecosystems, and economies, and improved water, food and nutrition security.

9. Economic growth must be of high quality and inclusive. It should occur hand in hand with relevant efforts to accelerate progress in global health, gender equality and women?s empowerment, the realization of human rights, greater equity, improved access to and quality of social protection, the rule of law, and the fair distribution of the benefits of development. Policies must avoid trade protectionism and negative impacts especially on the poor and vulnerable groups such as refugees and internally displaced persons. These objectives are all key elements of the green economy approach, and we pledge the support of our organizations to Member States as they engage in this critical and transformational transition.

10. The shift to sustainable development presents challenges, but also offers opportunity for substantial investments, both public and private, in productive infrastructure, technological transformation, science, education and human capital development. WHO as part of the UN system stands ready to assist Member States as they formulate and implement the enabling policy and regulatory frameworks that are essential for such investment to take place, and to continue to strengthen its work at the country level.

11. In the current fragmented system, institutional reform is unquestionably needed at national, regional and international levels, to integrate the dimensions of sustainable development, improve effectiveness in implementation, urgently scale-up activities, and bring about further coordination and coherence of policy.

12. The UN system is determined to do its part on institutional reform, by improving system-wide coordination mechanisms, and by reviewing and improving policies and programmes, including through joint programming. But this may not be sufficient, and Rio+20 should consider continued efforts on broader reforms within the UN system, for example, the strengthening of institutions, mandates and regulatory frameworks, or making structural changes.

13. At Rio+20, we must build on and scale up the achievements, best practices and lessons of the MDGs, and lay strong foundations for the post-2015 development agenda. We must chart a course for measurable progress towards sustainable development goals, using milestones that integrate the economic, environmental and social dimensions and a new generation of metrics to measure our achievements. The UN system stands ready to support the world?s nations and peoples to make sustainable development a reality.

Health and Sustainable Development

14. Healthy populations are central to human progress and sustainable development. This was recognized in the Rio Declaration of 1992 and remains equally true today. Rio +20 now offers an opportunity to re-examine the relationship between health and sustainable development. It does so at a time of global uncertainty; at time when the world is reacting to the on-going impact of financial and other crises; and at a time of growing inequities within and between countries. The key messages in this note are that improvements in human health contribute to the achievement of sustainable development, that they are one of its principal beneficiaries, and - of particular importance in this context - health indicators provide a convincing and powerful means for measuring progress.

15. The links between better health, the economy and the environmental sustainability are well established: people who are healthy are better able to learn, to earn and to contribute positively to the societies in which they live. Conversely, a healthy environment is a prerequisite for good health. Reduction of key air, water and chemical pollution risks can prevent up to a quarter of the total burden of diseases, and a large proportion of childhood deaths. Strong, well-designed health delivery systems not only protect individuals from illness but contribute to the resilience of societies by protecting people from impoverishment when they are sick. They can further the empowerment of women. And they represent a means by which people can hold national authorities democratically accountable.

16. Health is both a global as well as a national public good: clearly seen through the measures taken to address cross-border threats. These can take many forms: acute outbreaks that threaten travel, trade and economic growth; refugee crises and demographic shifts. Urbanization, along with its many benefits, has also fostered unhealthy slum environments, unhealthy lifestyles and changing patterns of consumption which all contribute to the growing burden of non-communicable disease - one of the greatest current threats to sustainable economic growth world-wide. A changing climate not only increases the frequency and intensity of natural disasters, but in the longer term threatens the fundamental requirements for health - clean air, safe drinking water, a secure food supply and adequate nutrition and shelter.

Progress, threats and opportunities

16. While there have been major advances in human health over the last two decades, these benefits have been unequally shared. At current rates of progress, for example, only 19 countries will reach the MDG target for reducing maternal mortality by 2015. It is also evident in areas such as improving access to medicines and other benefits of technology, that progress has been constrained by policies and practices in other sectors. As noted in the preamble, the last 20 years has seen limited progress in the integration of economic, environmental and social policy. Rather, there has been a continuing assumption that macroeconomic policy should be set independently and that economic growth, combined with the focus provided by the MDGs, would drive development. So despite a growing recognition that progress in health depends on trade, intellectual property, agriculture, employment and many other aspects of international and domestic policy - coherence across sectors remains elusive.

17. The series of global crises that provide the backdrop for Rio + 20 can open an opportunity for doing policy differently by creating greater awareness of the linkages among macroeconomic, social and environmental policies. Stimulus packages in some parts of the world have deliberately focused on infrastructure development for health. There is also growing consensus - not least within the G20 - of the need for better approaches to social protection. The challenge for health and sustainable development is to further develop an approach to policy which reflects interdependence and linkages, first at the national level and, building on this, at the global level.
Health and the Green Economy

18. While health can be major beneficiary of economic and environmental development, it will not happen automatically. The need for a new, more coherent approach to policy is well illustrated by the fact that twenty years after the first Rio Summit, the key decisions in many countries that guide urban planning, transport and housing development create rather than reduce air pollution, noise and traffic injuries. These same policies limit rather than promote daily physical activity. Likewise, there are too many instances in which energy policies worsen indoor air pollution, which is responsible for nearly half of the global pneumonia deaths in children under the age of five, and over 1 million deaths from chronic lung diseases, mostly among poor women. Agricultural policies too often make it harder, not easier to access to healthy foods and nutrition - in rural and urban areas and in developed as well as in less developed countries. The net result is that - in the absence of fundamental change - policies that govern the environment in which we live and work will continue to contribute to, and even exacerbate, the burden of disease. This is particularly true of chronic non-communicable conditions such as asthma, diabetes, cancers and heart disease . But equally poor housing and sanitation play a critical role in the transmission of diarrhoea, TB, and vector born diseases

19. Recent work in WHO shows that this need not be the case. Many health risks can be prevented and health benefits enhanced by a more integrated approach to policy making. Such approaches ensure that health and human well-being, equity and poverty eradication are the outcomes of development, and not factors to be traded off against economic growth alone. Clearly a green economy must contribute to income growth, to job creation, as well as to more sustainable patterns of consumption and production. And these need not be mutually exclusive if the right mix of strategies is chosen. The challenge therefore is to bring to bear the growing body of knowledge that links economic and environmental development with better health, and to ensure that this information can be accessed in usable, practical form by policy makers. Rio +20 offers an important opportunity in this regard.

The need for win-win solutions

20. Many of the big issues facing the world at the beginning of the second decade of the 21st century are well known: ageing populations; rapid, unplanned Urbanization; competition for scarce natural resources; financial instability; migration; and the effects of a changing climate. What is needed is a framework that links decisions in one area (such as urban planning or climate change mitigation) with better health and well being.

21. In respect of climate change mitigation, many parts of the framework have already been developed . Box 1 shows a brief selection of some win-win solutions for health and climate change mitigation in relation to the transport sector, household energy, housing and health facilities.

Box 1:

Greener health facilities as engines for community development:

Health care facilities worldwide are developing cleaner, greener, community-based energy and waste management systems ? generating significant, combined benefits for health, development and climate change adaptation/mitigation. Hospitals and clinics that gain greater energy self-sufficiency are more resilient to climate change and weather emergencies, and better able to provide services reliably to the urban and rural poor. Energy designs can range from advanced co-generation of heat and power (CHP), to small, "solar suitcases" that deliver light to midwives in remote settings. Improved low-energy, natural ventilation in hospital settings can support better infection control. Advanced autoclaving of health care waste can save reduce pollution emissions and dispose of hazardous medical waste more sustainably. Solar refrigeration also being scaled up in many rural locales to meet the fast-growing future demand for vaccine delivery and storage. Many energy retrofits can yield immediate, annual facility savings on the order of 10-30% - in a sector estimated to account for 5-7% of national greenhouse gas emissions in some developed countries. - Tens of thousands of health care providers from China and India to Europe and the Americas, already have launched energy and climate initiatives, driving change from the grassroots. However, health care systems in low income countries and rural settings require more support from climate finance mechanisms to adopt these cost-saving, climate- and life-saving measures.

Greener transport: More investment in bus rapid transit/urban rail, along with networks for cyclists and pedestrians yield: comparatively lower levels of urban air pollution; more physical activity; less traffic injury risks for cyclists and pedestrians traveling on separated networks; and better mobility for poor and vulnerable groups. Studies of urban cycle commuters in Shanghai and Copenhagen have shown 30% lower annual mortality risks, on average, in comparison to other commuters. Developing cities such as Curitiba, Brazil and Bogota, Columbia have made large, strategic investments in greener and healthier transport systems, largely self-financed. These emphasize dedicated bus lanes and extensive development of cycle/pedestrian routes, including in rapidly growing areas of the periphery.

Greener housing and home energy systems: Better home insulation, heating/cooking systems and indoor ventilation, can significantly help reduce respiratory diseases, including asthmas, pneumonia and TB, as well as vulnerability to extremes of heat and cold. The savings in health costs can help drive "health-wise" green investments. For instance, the benefit-cost ratio of an improved biomass stove in the average poor home in Africa or Latin America is 62:1, when gains in health as well as time and fuel savings are considered. These stoves also reduce climate changing black carbon. Large savings in health costs from asthmas and other respiratory illness were obtained from home insulation initiatives in low-income New Zealand homes. These immediate health gains helped drive large-scale government investments in home improvements ? although the economic value of the carbon savings would be realized in the future.

22. Similarly joined-up approaches to policy linkages are needed in other areas such as health care delivery. In the case of the former, the combination of ageing populations, growing public expectations, rising technology costs and an increasing burden of chronic disease threatens not just the financial sustainability of health systems but of whole economies . Policy needs to link measures across several sectors that can reduce the burden of chronic conditions; to change behaviours among health care providers, patients and financiers (including insurance companies); to ensure that incentives drive greater efficiency.

23. Social protection provides a third example of the policy coherence which links environmental, economic and social policy. In too many societies people remain vulnerable to sudden crises: through loss of jobs; through crop failure; or through accident or illness. Financial uncertainty and environmental change exacerbates these risks. The first change that is needed is to recognize that for enabling people and communities to be more resilient through social protection it needs to be seen as investment and not consumption. In other words, social protection has benefits both in terms of the economy (as an automatic stabilizer) and in terms of health outcomes.
Second there is a need to link different types of protection (crop insurance, old age pensions, remittance transfers); resources that enable access to basic services (such as health and education); and financing for the provision of those services.

Health as an outcome of all policies: measuring progress and impact

24. Sustainable development is sometimes a hard concept to grasp. Health is not. Demonstrating the relationship between the two is therefore a powerful argument to support climate change mitigation and adaptation in particular, and sustainable development in general. Its benefits are usually immediate, personal and local ? rather than deferred and diffuse, like reducing CO2 emissions. Opinion surveys of the general public, and of climate negotiators, as well as economic valuation of health effects of mitigation and adaptation measures, all argue for a much stronger role for health in climate and related development processes.

25. Rio + 20 provides an opportunity to agree on a new approach to development based on the integration of economic, environmental and social policy concerns. For any new approach to have real traction, however, new metrics will be needed to assess progress. These may take the form of Sustainable Development Goals or a new MDG framework.

26. Health outcomes can be measured and can generate public and political interest. In addition, WHO has developed tools and indicators to assess the impact of policies in different sectors and their potential impact on peoples' health. Health indicators alone cannot convey progress on development, but as both contributor and beneficiary of sustainable development, they will be a critical component to how we track the progress and impact of sustainable development after Rio +20.